Individual Childcare Form for Caregiver

Program ID#_____ Classroom ID#_____ Caregiver ID#___________ Child ID#___________

Do not write in box. For study use only.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific program or individual. We will not provide information that identifies you or your program to anyone outside the study team, except as required by law.

INSTRUCTIONS TO CAREGIVER: Please fill out one of these forms for each child. “The child/this child” is used throughout this form to refer to the child whom you name below.

6. INDIVIDUAL CHILD FORM FOR CAREGIVER

Child’s name: FIRST____________________ LAST___________________________

Child’s relationship with you

1. For each statement listed below, please circle the number corresponding to how much it is true for your relationship with this child. Would you say the statement is never true=0, sometimes true=1, or always true=2?

		Never	Sometimes	Always
a.	If upset, this child will seek comfort from me. …………………………………………………..	0	1	2
b.	This child and I always seem to be struggling with each other…………………………….	0	1	2
c.	This child is uncomfortable with physical affection or touch from me……………………	0	1	2
d.	This child remains angry or is resistant after being disciplined……………………………..	0	1	2
e.	When this child arrives in a bad mood, I know we’re in for a long and difficult day..	0	1	2
f.	It is easy to be in tune with or to know what this child is feeling…………………………	0	1	2

Child’s behavior

2. Below are some descriptions of what infants or toddlers may be like at the child’s age. For each description please circle the number corresponding with the response that best indicates how this child is. Would you say that the child is never like this=0, used to be like this=1, is like this sometimes=2, or is like this most times=3?

		Never like this	Used to be like this	Is like this sometimes	Is like this most times
a.	He/She is frequently irritable or fussy ………………………………..	0	1	2	3
b.	He/She goes easily from a whimper to an intense cry…………..	0	1	2	3
c.	He/She is unable to wait for food or toys without crying or whining or falling apart …………………………………………………….	0	1	2	3
d.	He/She is easily distractible or has fleeting attention……………	0	1	2	3
e.	He/She tunes out from activity and is difficult to reengage ….	0	1	2	3
f.	He/She can’t shift focus easily from one subject or activity ….	0	1	2	3
g.	He/She is bothered by changes in the daily routine …………….	0	1	2	3
h.	He/She is easily frightened ……………………………………………….	0	1	2	3

Child’s language

3. On the whole, which of these statements best describes the way this child communicates? Would it be . . .

• The child repeats sounds (e.g., cooing or making vowel-like sounds, “oooh, ah,” etc.).

• The child’s sounds have a speech-like babble to them (e.g., babamama).

• The child tells you by sound or gesture when he or she wants something or does not want something.

• The child imitates speech sounds, and he or she may have 1 or 2 words (e.g., "bye-bye," "baba" for bottle, and "no")

• The child is mostly talking in one-word sentences, such as “milk” or “down”

• The child is talking in 2 to 3 word phrases, such as “give doll” or “me got ball”

• The child is talking in fairly complete short sentences, such as “I got a doll” or “can I go outside?”

• The child is talking in long and complicated sentences, such as “when we went to the park, I went on the swings” or “I saw a man standing on the corner”

4. To talk about activities, we sometimes add “ing” to verbs. Examples include looking, running and crying. Has this child begun to do this?

• No

• Yes

5. To talk about things that happened in the past, we often add “ed” to the verb. Examples include kissed, opened, pushed. Has this child begun to do this?

• No

• Yes

Thank you for taking the time to complete this form.

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